Dermoscopy Enables Early, Noninvasive Detection of ICI-Related Skin Toxicities in Melanoma

This article was originally published by Dermatology Times^®.

Dermoscopy can noninvasively identify immune checkpoint inhibitor (ICI)–related skin toxicities early in patients with melanoma, guide management, and reduce the need for biopsies, according to a recent study published in Frontiers in Immunology.¹

ICIs have revolutionized the treatment of melanoma, offering significant survival benefits for patients with advanced disease. However, their use is associated with a spectrum of immune-related adverse events (irAEs), among which cutaneous toxicities are notably common. Often recognized as the first signs of irAEs, these skin reactions can range from mild rashes to severe, life-threatening conditions. Accurate and prompt diagnosis is crucial to managing these toxicities effectively, minimizing treatment disruptions, and optimizing patient outcomes.

Recent literature emphasizes the importance of integrating dermoscopy into the diagnostic process of ICI-induced cutaneous toxicities.² While previous studies primarily relied on clinical and histopathological assessments, a more recent review highlights the potential of dermoscopy as a rapid, non-invasive tool that can facilitate early identification and characterization of these reactions.¹

The prevalence of skin irAEs in patients undergoing ICI therapy is considerable, with reports indicating that approximately 25% of patients develop dermatologic manifestations. These lesions often present as erythematous maculopapular eruptions, lichenoid features, psoriasis-like changes, or vitiligo-like discolorations. Researchers behind the recent publication said early manifestations typically involve diffuse erythema, pruritus, and individual or coalescing papules, often involving the trunk and extremities.

Dermoscopy reveals various characteristic features that mirror those seen in classical dermatologic conditions, aiding clinicians in differentiating between benign reactive processes and more severe or atypical reactions. For inflammatory eruptions such as eczema-like reactions, researchers noted that dermoscopy often shows dotted vessels clustered on a pink-red background, coupled with white scaling and crusting. In cases resembling psoriasis, regularly distributed dotted vessels on a light background, along with diffuse scaling, are typical. Vitiligo-like depigmentation may display a depigmented, homogeneous appearance under dermoscopy, helping to confirm the diagnosis without invasive biopsy.

The recent review underscores that dermoscopy can enhance diagnostic accuracy, particularly in the early stages when clinical presentation may be ambiguous. It also allows for monitoring lesion evolution, guiding biopsy decisions when necessary, and distinguishing between inflammatory and bullous or lichenoid reactions. This is especially relevant in severe cases indicated by histopathology, such as in bullous diseases like bullous pemphigoid or lichenoid reactions.

Importantly, the occurrence of cutaneous irAEs has been linked with better tumor response and improved survival outcomes in melanoma. While the precise mechanism remains unclear, the presence of skin toxicity is thought to reflect a robust immune activation against tumor cells. Therefore, recognizing these reactions early and accurately can inform treatment decisions, balancing the continuation or modification of immunotherapy with the management of adverse effects.

Advancing knowledge in this field calls for larger, prospective studies incorporating standardized dermoscopic criteria and imaging protocols. Such efforts will validate the current findings and facilitate the integration of dermoscopy into routine management pathways for melanoma patients on ICIs.

Overall, dermoscopy emerges as a valuable adjunct to clinical examination in the early detection and management of ICI-related cutaneous toxicities. Its ability to provide rapid, in vivo insights into skin lesions can reduce reliance on invasive biopsies, accelerate treatment adjustments, and ultimately support better patient outcomes. As immunotherapy continues to expand its role in melanoma management, dermatologists will increasingly need to familiarize themselves with the dermoscopic features of these toxicities to optimize care and supervision.

References

1. Liang Y, Zheng Y, Zeng Y, et al. Immune checkpoint inhibitors in melanoma: mechanisms, immune cell interactions, and the tumour microenvironment. Front Immunol. 2025. doi:10.3389/fimmu.2025.1691608
2. Kaminska-Winciorek G, Zalaudek I, Zarańska K, Cybulska-Stopa B. Immunotherapy‐related cutaneous toxicities in melanoma: a dermoscopic perspective. JEADV Clin Prac. 2026. doi:10.1002/jvc2.70294.